Unusual Cause of Gastrointestinal Bleeding in an Elderly Adult: Gastric Kissing Ulcers

Cite this article as: Yüksekyayla O, Batıbay E, Efe C. Unusual cause of gastrointestinal bleeding in an elderly adult: Gastric kissing ulcers. Turk J Gastroenterol. 2024;35(5):421-422.

Dear Editor, Upper gastrointestinal bleeding (UGIB) is a medical emergency and is associated with high mortality and morbidity.UGIB is defined as bleeding in the esophagus, stomach, or proximal part of duodenum. 1Peptic ulcers resulted from Helicobacter pylori infection and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) or antithrombotic agents, are the most common cause of UGIB worldwide. 1,2issing ulcers are defined as the pair of ulcers facing each other on the opposite walls of the stomach or duodenum. 3issing ulcers are commonly observed in the duodenum but very rarely seen in the stomach.We report a case of kissing gastric ulcers presenting as melena in a patient on warfarin therapy.
A 82-year-old man was admitted to the hospital for abdominal pain and melena.The patient was under anticoagulation with warfarin (5 mg/daily) because of mitral valve replacement that performed 10 years earlier.On examination, blood pressure was 105/65 mm Hg and heart rate was 105 beats/min.Abnormal laboratory results were as follows: hemoglobin 8.4 g/dL, hematocrit 26, and international normalized ratio (INR) 2.4.Previous hemoglobin and INR levels were 12.2 g/dL and 2.6 respectively, approximately 6 weeks ago.An upper gastrointestinal endoscopy showed 2 circular, kissing ulcers which had clean bases covered by whitish exudate, and surrounded by normal gastric mucosa without active bleeding.They were located in the anterior (size, 27 × 20 mm) and posterior walls (size, 15 × 20 mm) of the distal corpus (Figure 1).Biopsy samples from the margin and base of the ulcers did not reveal any malignancy and helicobacter pylori was negative.He was treated with a proton pump inhibitor (rabeprazole 2 × 20 mg/day) and discharged from the hospital with no complications in a week.
4][5][6][7][8] In previous reports, development of gastric kissing ulcers was attributed to abdominal blunt trauma in 4 cases, 3,[6][7][8] NSAIDs intake in 1 case, 4 and the etiology was unknown in another case. 5Our patient did not have any history of trauma or the use of NSAIDs.Only the use of warfarin might be a risk factor for the development of gastric ulcers.
A previous experimental study showed that proton pump inhibitors effectively induced mucosal healing of kissing gastric ulcers in rats. 9Similar to previous reports, 3,6,7 we also successfully treated our patient with proton pump inhibitors.The outcome of reported cases with kissing gastric ulcers was generally good, except in 1 case, kissing gastric ulcers complicated by acute pancreatitis and portal biliopathy. 5This adverse outcome suggests that early diagnosis and prompt treatment of kissing gastric ulcers are crucial.
We described a case of kissing gastric ulcer, which was diagnosed in a patient on warfarin therapy.Though rare, gastric kissing ulcers should be considered among the differential diagnosis of patients presenting with upper gastrointestinal bleeding.

Declaration of Interests:
Cumali Efe is an associate editor at the Turkish Journal of Gastroenterology, however, his involvement in the peer review process was solely as an author.Other authors have no conflicts of interest to declare.
Funding: This study received no funding.

Figure 1 .
Figure 1.Kissing ulcers are seen in the anterior and posterior walls of the distal corpus.